I have trained many cath lab staff across the nation during my career. One of my duties has been to train cath lab and intensive care unit (ICU) staff members how to correctly pull a sheath. I have found people often have different views on how to pull sheaths, varying from using fingers to using their fist or a FemoStop device (St. Jude Medical). The most frequent complaint I have heard relates to holding pressure for a long period of time, which in turn makes the fingers or hand hurt or go numb.
I feel there is only one way to pull a sheath correctly. I know that holding pressure in one place for a long period of time can hurt. Yet holding pressure has to be done correctly every time, the same way, in order to minimize complications.
The problem with using a fist to hold pressure is that you are unable to feel the patient’s pulse. While pulling a sheath, it is important to be able to feel the patient’s pulse at all times to be certain you are holding in the correct area.
Following are my recommendations for pulling a sheath:
- Take your index, middle and sometimes your ring finger, and place them slightly above the sheath to feel the patient’s pulse. This will tell you exactly where the artery is that you are holding.
- Slowly remove the sheath in a sterile manner, holding occlusive pressure to avoid bleeding.
- To minimize hand or finger pain, place your other hand on top of your pressure hand. In this way, you can alternate which hand is holding the pressure without having to remove your fingers.
Using this method to pull sheaths is safer than pulling with your fist. If you are using your fist, by the time you realize your pressure has slipped off the artery, the patient may have a large hematoma.
It seems like every different cath lab has different hold times, which is fine. It is important to abide by your hospital’s policies. My own hold times are simple. Any artery that is pulled with 7 French or less (adding 5 minutes per additional sheath size), I hold for 20 minutes. For the first 5 minutes, holding full pressure, then releasing slightly every 5 minutes to where the last 5 minutes is light pressure.
If I am pulling a venous sheath, I hold for 10 minutes regardless of whether it is internal jugular, femoral, etc. Do not hold as much pressure as with an artery; remember it is venous. The entire time I hold pressure, whether arterial or venous, I am constantly accessing and feeling around the site, looking for any bleeding. I like to have atropine available if needed for vagal reactions.
Most of the time at our lab, we close the artery using a closure device. The closure device we use the most frequently is the Perclose (Abbott Vascular). There are physicians that are opposed to using closure devices. Using a closure device when the indications are optimal is a nice convenience for the patient, with less down time needed. Closure device companies will send out their representatives to certify physicians and employees.
Arterial and venous sheaths
For those that are uncertain which sheath to pull first when both arterial and venous sheaths are present, I always tell people to go ahead and pull the arterial sheath first. There are many reasons why I would suggest this be the case. The main reason is that it takes longer for the arterial sheath to obtain hemostasis. Having large venous access while holding the arterial sheath is not a bad idea if for some reason you need it for medication or intravenous access. Many people like to pull both sheaths together. If you are going to do this, I suggest pulling the arterial sheath first and after 10 minutes, pull the venous sheath. Remember, you can run into complications if you are not completely holding correct pressure. So I suggest pulling one sheath at a time to reduce the risks of complications.
Pulling sheaths requires very serious attention to technique. Labs should have staff with the skills necessary to accomplish this task correctly.
If you or your cath lab would like more advice on pulling sheaths, I would be happy to cover this technique in depth upon request at firstname.lastname@example.org. Follow Phillip on Twitter.com @phillip_mumford